DECREASE IN NOSOCOMIAL CLOSTRIDIUM-DIFFICILE-ASSOCIATED DIARRHEA BY RESTRICTING CLINDAMYCIN USE

Objective: To report the investigation and effective control of a noso comial epidemic of Clostridium difficile-associated diarrhea. Design: Concurrent surveillance for identification of new nosocomial cases, re trospective case-control analysis, and hospital formulary control of a ntibiotic use. Setting: University-affiliated Veterans Affairs Medical Center located in southwestern United States. Patients: Hospitalized patients who developed diarrhea submitted stool specimens for cytotoxi n assay. Patients who were positive for cytotoxin were compared with c ontrol patients without infection. Measurements: Isolates of C. diffic ile were typed by restriction endonuclease analysis. Antimicrobial age nt use from hospital pharmacy records and selected patient data from c hart review were correlated with frequency of specific laboratory abno rmalities. Results: For 13 months, the monthly incidence of C. diffici le infection averaged more than five times that for the previous 21 mo nths. Stool specimens from 34 patients (59%) contained a single strain (restriction enzyme analysis type J7). Clindamycin was statistically associated with the epidemic as shown by the following: clindamycin us e at our center compared with national normal values, clindamycin use for years before compared with during the epidemic, monthly use of cli ndamycin compared with monthly frequency of infection, frequency of in fection in patients receiving clindamycin compared with that in patien ts receiving other antimicrobial agents, and amount of clindamycin use d by infected patients compared with that used by control patients. Re stricting clindamycin use led to a prompt decrease in infection rate a nd the type J7 organisms. Conclusion: A nosocomial epidemic of C. diff icile diarrhea was controlled by analysis of antibiotic use patterns a nd by subsequent restriction of clindamycin.